PROBLEM/ NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

CUES DIAGNOSIS
OBJECTIVES CUES: Ineffective cerebral SHORT TERM: 1. Determine history of 1. To identify client at SHORT TERM:
tissue perfusion After 4 hours of conditions associated risk for decrease After 4 hours of
CT Scan Result: related to head nursing intervention with thrombus or cerebral perfusion nursing
Indicate left fronto- trauma the patient should be emboli such as stroke. related to bleeding intervention the
parietal subdural able to: and/or coagulation patient was able
hematoma of problem. to:
thickness 2.4cm and 1. Verbalize
midline shift from L- understanding of 2. Note current 2. Those condition can 1. Verbalize
R of about 0.7cm. condition, therapy situation of presence of affect multiple body understanding of
regimen, side effects conditions such as system and systemic condition, therapy
GCS =11-moderate of medications and (CHF, major trauma, circulation/ perfusion. regimen, side
E- 4- open when to contact sepsis, HPN) effects of
spontaneously health care provider. medications and
V-2- sounds 3. Ascertain potential or 3. These conditions when to contact
M-5- localizing 2. Demonstrate presence of conditions Alter the relationship health care
behaviors and lifestyle such as tumors, between intracranial provider.
Restlessness changes to improve hemorrhage, anoxic Volume and pressure,
(+)nausea and circulation brain injury associated potentially increasing 2. Demonstrate
vomiting with cardiac arrest and intracranial volume behaviors and
Headache LONG TERM: toxic or viral and pressure, lifestyle changes to
Body weakness encephalophaties. potentially increasing improve circulation
1. Display ICP and decreasing
neurological signs cerebral perfusion. LONG TERM:
within client normal
range. 4. Evaluate blood 4. Chronic or severe 1. Display
pressure. acute hypertension can neurological signs
precipitate within client
cerebrovascular normal range.
spasms and stroke.

5, Maintain head of the 5. To promote optimal

bed at least 15-30 cerebral perfusion.
degree as indicated.

DEPENDENT:
6. Administer 6. To increase cardiac
vasoactive medication output and /or
as indicated. adequate arterial
blood pressure to
maintain cerebral
perfusion.

7. Administer other 7. Anti-hypertensive to

medications as manage high blood
indicated. pressure and anti-
Amlodipine 5mg OD coagulant to prevent
Tranexamic acid cerebral embolus.
Hemostan

COLLABORATIVE: 8. Evacuation of
8. Prepare client for hematoma may
surgery as indicated. improve cerebral
perfusion.

9. Refer to educational 9. Client/ SO may

and community benefit from
resources as indicated. instruction and support
provided agencies to
engage in healthy
activities.
 PROBLEM/ NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
CUES DIAGNOSIS
OBJECTIVE CUES: Fluids and Short term: INDEPENDENT: Sodium imbalances After 8 hours of
electrolytes deficit After 8 hours of Monitor level of may cause changes nursing intervention
Seizures, related to nursing intervention consciousness and that vary from patient was free from
Headache hypernatremia the patient will be muscular strength, irritability and neuromuscular
Confusion able to cope with tone, and movement. confusion to seizures irritability and
Loss of energy and neuromuscular and coma. In the cognitive
fatigue irritability and presence of a water impairment.
Restlessness and cognitive impairment deficit.
irritability Lab result.
Muscle weakness Long Term: Na-145
After 1 week of
Lab. nursing intervention Provide safety and Decrease in sodium
4 consec.lab. the patient will be seizure precaution as level increase the risk
Na- 131 mEq/L able to display indicated: of convulsions.
132 mEq/L laboratory results Bed in a low position.
NORMAL VALUE especially Na within Use of padded side
135-145 mEq/L the normal limit. rails.

Encourage meticulous Maintains integrity of

skin care and frequent the skin.
repositioning.

Provide frequent oral Promotes comfort

care. Avoid the use of and prevent further
mouthwash containing drying of mucous
alcohol. membranes.

Encourage increase oral Replacement of total

and IV fluid intake. body water deficit
will gradually restore
sodium and water
 balance.

Monitor serum This will evaluate the

electrolytes, osmolality, therapy needs and
and arterial blood effectiveness.
gasses, as indicated.

DEPENDENT:
Administer medication Used to replace
as ordered: deficits in the
Sodium Chloride presence of chronic
or ongoing losses.

COLLABORATIVE:
Monitor laboratory Normal value of
result of sodium level. sodium level helps
cells function
normally and helps
regulate the amt of
fluid in the body

PROBLEM/ NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

CUES DIAGNOSIS
OBJECTIVES: Impaired Physical After 8 hours of INDEPENDENT: These measures After 8 hours of
Imposed Mobility related nursing intervention, Present a safe promote a safe, secure nursing intervention,
restrictions of to contraptions patient should be environment: bed rails environment and may patient should be
movement (intubation). able to : up, bed in down reduce risk for falls. able to :
(+) ET position, important
(+) ECG electrodes Maintain/increase items close by. Patient able to
strength and function Reduces risk of tissue display an increase
of affected or Change positions at injury. Affected side has strength and function
compensatory body least every 2 hr (supine, poorer circulation and of affected or
part. side lying) and possibly reduced sensation and is compensatory body
more often if placed on more predisposed to skin part.
Maintain optimal affected side. breakdown.
position of function Maintained optimal
as evidenced by Inspect skin regularly, Pressure points over position of function
absence of particularly over bony bony prominences are as evidenced by
contractures. prominences. Gently most at risk for absence of
massage any reddened decreased perfusion. contractures,.
Demonstrate areas and provide aids Circulatory stimulation
techniques/behaviors such as sheepskin pads and padding help
that enable as necessary. prevent skin breakdown Demonstrate
resumption of and decubitus techniques/behaviors
activities. COLLABORATIVE: development. that enable
resumption of
Maintain skin Provide egg-crate Promotes even weight activities.
integrity. mattress, water bed, distribution, decreasing
flotation device, or pressure on bony points Maintain skin
specialized beds, as and helping to prevent integrity.
indicated. skin breakdown and
decubitus formation.
Specialized beds help
with positioning,
enhance circulation, and
reduce venous stasis to
decrease risk of tissue
 injury and complications
such as orthostatic
pneumonia.

Establish measures to This is to prevent skin

prevent skin breakdown breakdown, and the
and thrombophlebitis compression devices
from prolonged promote increased
immobility: venous return to prevent
Clean, dry, and venous stasis and
moisturize skin as possible
necessary. thrombophlebitis in the
Use anti embolic legs.
stockings or sequential
compression devices if
appropriate.
Use pressure-relieving
devices as indicated (gel
mattress).

PROBLEM/ CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

OBJECTIVE CUES: Impaired Oral After 8 hours of INDEPENDENT: After 8 hours of

mucous membrane nursing intervention, Routinely inspect oral Early identification of nursing intervention,
Sores located @ the cavity, teeth, gums problems provides
related to presence of the patient will be the patient be able
tongue and gums. tube in mouth as able to: for sores, lesions, opportunity for to:
evidence by sores in bleeding. appropriate
the tongue and gums. intervention/
Report/demonstrate preventive measures. Report/demonstrate
a decrease in a decrease in
symptoms. Administer mouth Prevents symptoms.
care routinely and as drying/ulceration of
needed, especially in mucous membrane
Identify specific patient with an oral and reduces medium Identified specific
interventions to intubation tube, e.g., for bacterial growth. interventions to
promote healthy oral cleanse mouth with promote healthy oral
mucosa as water, saline, or mucosa as
appropriate. preferred appropriate.
mouthwash.

Brush teeth with soft

toothbrush, Promotes comfort.
Waterpik, or
moistened swab.
Reduces risk of lip
Change position of
and oral mucous
ET/airway on a
membrane
regular/prn schedule
ulceration.
as appropriate.

Maintains moisture,
Apply lip balm;
prevents drying.
administer oral
lubricant solution.
 PROBLEM/ NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
CUES DIAGNOSIS
Impaired ability to Self-Care Deficit After 8 hours of INDEPENDENT Aids in planning for After 8 hours of
put on or take off related to nursing intervention Assess abilities and meeting individual nursing intervention
clothing. Neuromuscular the patient should be level of deficit (04 needs. the patient should be
impairment as able to: scale) for performing able to:
Inability to bathe and evidenced by Demonstrate ADLs. Demonstrate
groom self Impaired ability to techniques/lifestyle Avoid doing things for To maintain self- techniques/lifestyle
independently perform ADLs. changes to meet self- patient that patient can esteem and promote changes to meet self-
care needs. do for self, but provide recovery, it is care needs.
Perform self-care assistance as necessary. important for the
activities within level patient to do as Patient performed
of own ability. much as possible for self-care activities
Identify self. These patients within level of own
personal/community may become fearful ability.
resources that can and independent,
provide assistance as although assistance Identify
needed. is helpful in personal/community
preventing resources that can
frustration. provide assistance as
needed.
Determine the specific Various etiological
cause of each deficit factors may need
(e.g., visual problems, more explicit
weakness, cognitive interventions to
impairment). enable self-care
Be aware of impulsive May indicate need
 actions suggestive of for additional
impaired judgment. interventions and
supervision to
promote patient
safety.

PROBLEM/ NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

CUES DIAGNOSIS
OBJECTIVE: Risk for aspiration After 8 hours of INDEPENDENT: After 8 hours of
(+) NGT pneumonia related nursing interventions Assess level of The primary risk nursing interventions
(+) ET to presence of the patient will be consciousness. factor of aspiration is the patient will be
nasogastric feeding able to : decreased level of able to :
consciousness.
Patient is free of Free of signs of
signs of aspiration Monitor respiratory Signs of aspiration aspiration and the
and the risk of rate, depth, and effort. should be identified risk of aspiration is
aspiration is Note any signs of as soon as possible to decreased.
decreased. aspiration such as prevent further
dyspnea, cough, aspiration and to Expectorates clear
Patient expectorates cyanosis, wheezing, or initiate treatment secretions and is free
clear secretions and fever. that can be life- of aspiration.
is free of aspiration. saving.
Maintained a patent
Patient maintains a Assess pulmonary Aspiration of small airway with normal
patent airway with status for clinical amounts can happen breath sounds.
normal breath evidence of aspiration. with sudden onset of
sounds. Auscultate breath respiratory distress
sounds noting for or without coughing
Patient swallows and crackles and rhonchi. particularly in
digests oral, Monitor chest x-ray patients with
nasogastric, or films as ordered. diminished levels of
gastric feeding consciousness.
without aspiration. Pulmonary infiltrates
 on chest x-ray films
indicate some level
of aspiration has
already occurred.

Elevate the head of bed Upright positioning

to 30 to 45 degrees reduces aspiration by
while feeding the decreasing reflux of
patient and for 30 to 45 gastric contents.
minutes afterward if
feeding is intermittent.

For patients at high risk Continuity of care

for aspiration, obtain can prevent
complete information unnecessary stress
from the discharging for the patient and
institution regarding family and can
institutional facilitate successful
management. management in the
home setting.

Discuss to the patient Information helps in

the signs and symptoms appropriate
of aspiration. assessment of high-
risk situations and
determination of
when to call for
further evaluation.

Demonstrate on Respiratory
suctioning techniques aspiration requires
to prevent prompt action to
accumulation of maintain the airway
secretions in the oral and promote
 cavity. effective breathing
and gas exchange.

Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

Within 8 hrs
OBJECTIVE CUES: Risk for fall related to Within 8 hours of Independent:
of nursing
present condition nursing intervention
Keeping the beds closer to the intervention
manifested to body the patient will be
floor reduces the risk of falls the patient
(+) Body weakness weakness able to prevent from See to it that the
and serious injury. In some was able to
fall. beds are at the
healthcare settings, placing the defecate
lowest possible without
mattress on the floor
position. If needed, exerting any
significantly reduces fall risk.
set the patients effort.
sleeping surface as
adjacent to the floor
as possible.

A diary of bowel habits is

valuable in treatment of
constipation.

Have the client or

family keep a diary of
bowel habits
including time of day; Fluid intake must be within the
usual stimulus; cardiac and renal reserve.
consistency, amount, Adequate fluid intake is
and frequency of necessary to prevent hard, dry
stool; fluid stools. Increasing fluid intake to
consumption; and 1.5 to 2 L/day along with fiber
use of any aids to intake of 25 g can significantly
defecation increase frequency of stools in
clients with constipation.

Activity increases peristalsis to

Encourage a fluid
prevent constipation.
intake of 1.5 to 2
L/day (6 to 8 glasses
of liquids per day). If
oral intake is low,
gradually increase
fluid intake.
To soften the stools.

Encourage to do
passive exercise and
positioning every 2
hours.
 Dependent:

Administer laxatives
as prescribed.

Lactulose (Lilac)

Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

OBJECTIVE CUES: Risk for Constipation Within 8 hrs of Independent: Within 8 hours of
related to present nursing intervention nursing intervention
(+) Body weakness condition as the patient will be Items that are too far the patient will be
(+) ET manifested by able to prevent from Move items used by from the patient may prevented from fall.
immobility fall. the patient within cause hazard and can
easy reach, such as contribute to falls.
call light, urinal,
water, and
telephone. Keeping the beds
closer to the floor
reduces the risk of
falls and serious
See to it that the beds injury. In some
are at the lowest healthcare settings,
possible position. If placing the mattress
needed, set the on the floor
patients sleeping significantly reduces
surface as adjacent to fall risk.
the floor as possible.
Patients, especially
older adults, have
reduced visual
capacity. Lighting an
unfamiliar
environment helps
Guarantee increase visibility if
appropriate room the patient must get
lighting, especially up at night.
during the night.